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Full Address including postcode:

Date of Birth
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Membership Type (required)
First Claim - £32Second Claim - £20Social - £15

First Name Club (if other than Kippax)

Payment Method (required)
Bank Transfer (please see bank details below and make sure, your name is referenced)PayPalCash or Cheque at Club

Emergency Contact

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Declaration

I certify that the above information is true and correct to the best of my knowledge.
I understand that membership is voluntary and at my own risk.
I agree to abide by the rules and constitution of the club.
I agree to the information I have provided being stored on the club database, shared with other club members and for membership purposes.

By ticking this box, I confirm I have read and agree to the above declaration